Hemorrhoids Surgery

Although most cases of hemorrhoids can be treated with over the counter medications, in the home treatments, and changing one’s diet and nutritional habits, some times more drastic measures need to be taken.

For many years treatment of hemorrhoids has focused on alleviating sphincter hypertonia. Conservative therapy, consisting of sitz baths, topical anesthetics, and the use of bulking supplements, aims to alleviate pain and dilate the sphincter with large, soft stools.

There are several surgical techniques used to alleviate hemorrhoids. Most of these procedures can be performed as an outpatient.

In cases of severe, persistent pain, your physician may want to remove the hemorrhoid containing the clot with a small incision. This outpatient procedure generally provides relief and is performed under local anesthesia.

Operative therapy decreases sphincter pressures either by forceful dilation (increasingly of historical interest only) or, now far more commonly, by lateral internal sphincterotomy. Although this technique is a simple and effective outpatient surgical procedure performed under local anesthesia, its fundamental drawback is its potential to cause minor but sometimes permanent alterations in the control of gas, mucus, and occasionally stool. This problem has motivated a quest for pharmacologic ways to create a temporary or reversible “sphincterotomy,” one that would lower sphincter pressures only until the hemorrhoids have healed. Two such approaches have been identified.

The other pharmacologic approach to hemorrhoids involves the use of botulinum toxin. Once again, the aim is to decrease the resting anal pressure, in this case by preventing the release of acetylcholine from presynaptic nerve terminals. More famous as a lethal poison, botulinum toxin has found its way into the therapy of a number of skeletal-muscle disorders, including strabismus, blepharospasm, and spasmodic torticollis. Botulinum toxin has also been used for smooth-muscle disorders, including achalasia and detrusor dysfunction.

In a recently conducted double-blind, placebo-controlled study of botulinum toxin A in 30 patients with chronic hemorrhoids. Despite discrepancies in the randomization (more men and older patients in the control group), the results show a convincing therapeutic effect. After two months, 87 percent of the treated patients had symptomatic relief and 73 percent were healed, as compared with 27 percent and 13 percent, respectively, of the controls. Resting anal pressure decreased significantly in the treated patients but not in the controls.

All four patients with initial treatment failure healed after retreatment, as did 70 percent of the controls who crossed over to botulinum-toxin injection. Scanty data are presented with respect to alterations in continence, but it appears that only one patient who received toxin suffered temporary flatus incontinence. Similar results were recently reported by Jost, who noted healing in 79 of 100 patients six months after botulinum-toxin injection. Eight patients had early relapses, and seven had temporary gas or stool incontinence.

Additional treatments are:

Ligation – “the rubber band treatment” -a special instrument, fastens a tiny rubber band around the base of the hemorrhoid, tying it tightly and cutting off its blood supply. This works well on internal hemorrhoids that protrude with bowel movements. Both the hemorrhoid and the band fall off in a few days and the area heals in one to two weeks. Mild discomfort and bleeding can be a result of the “rubber band” treatment.

Rubber Band Ligation of Internal Hemorrhoids A. Bulging, bleeding, internal hemorrhoid B. A tiny rubber band is applied at the base of hemorrhoid C. About 7 to 10 days later, the banded hemorrhoid has fallen off leaving a small scar at its base (arrow)

Hemorrhoidectomy- “surgery to remove the hemorrhoids” – is the best method for permanent removal of hemorrhoids.
A Hemorrhoidectomy is often performed when:

(1) clots repeatedly form in external hemorrhoids;
(2) ligation does not work on the internal hemorrhoids;
(3) the protruding hemorrhoid has not been reduced in
size with medications;
(4) when bleeding cannot be controlled.

A hemorrhoidectomy is done under anesthesia and may require a hospital stay depending on the severity of the hemorrhoids.

Hemorrhoidectomies using a laser are also performed, but do not offer any advantage over standard operative techniques, and are no less painful and much more expensive.

Injection and Coagulation can also be used on bleeding hemorrhoids that do not protrude. Both methods are relatively painless and cause the hemorrhoid to shrivel up.

Other treatments include cryotherapy, BICAP coagulation and direct current. Cryotherapy, consists of freezing hemorrhoidal tissue with liquid nitrogen. This is not highly recommended for hemorrhoids since it is very painful. Cryotherapy is a temporary relief from symptoms and is not a “cure” for hemorrhoids. BICAP Coagulation and direct current treatment both shrink the hemorrhoid, but neither method is very popular.